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ABSTRACT: OBJECTIVES: This article reports the early clinical outcomes and experiences of Zenith pivot branch device (p-branch) standard fenestrated endovascular graft (Cook, Bloomington, Ind) for treating juxtarenal abdominal aortic aneurysm (AAA) originating below the superior mesenteric artery (SMA). METHODS: A physician-sponsored investigational device exemption study was used to assess enrolled elective and emergency patients from August 2011 to September 2012 for treatment with an off-the-shelf Zenith p-branch device. Patients were included provided an anatomic seal could be established 4 mm below the SMA and the renal geometry fit the protocol based on reconstructed computed tomography data. The celiac artery was addressed with a scallop and the SMA with an 8-mm fenestration. The renal fenestrations were constructed as a modified design to allow a range of renal locations (7.5 mm radially from the center of the fenestration) to be acceptably treated with a single configuration. Two anatomic configurations were created for renal arteries (origins at the same level, or disparate renal arteries with left lower than right). Outcomes are reported in coherence with endovascular reporting standards documents. RESULTS: The study enrolled 16 patients (94% men; median age, 75 years [range, 59-87 years]) with a median aneurysm size of 58 mm (range, 49-83 mm). Two were treated for aneurysm rupture. Technical success was achieved in all patients. The median fluoroscopy time was 62 minutes (range, 38-105 minutes), and the amount of contrast media was 69 mL (range, 31-121 mL). There were no aortic-related deaths, aneurysm ruptures, open surgical conversion, or type I/III endoleaks. One right renal artery occluded during follow-up in the setting of a conically shaped visceral aortic segment and was successfully treated with endovascular recanalization. CONCLUSIONS: The use of the p-branch device for aneurysms originating infra-SMA is associated with a high rate of technical success and minimal problems during the short follow-up duration. The off-the-shelf design allows for the treatment of ruptures and other urgent situations. Additional patients and more follow-up will be required to further define the risks and benefits of such a treatment strategy.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 04/2013; · 3.52 Impact Factor
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ABSTRACT: OBJECTIVE: Branched and fenestrated repair has been shown to be effective for treatment of complex aortic aneurysms. However, the long-term durability of branches is not well reported. METHODS: Prospective data collected for all patients enrolled in a physician-sponsored investigational device exemption trial for branched and fenestrated endografts were analyzed. Retrospective review of imaging studies and electronic records was used to supplement the dataset. Incidences of branch stent secondary intervention, stent fracture, migration, branch-related rupture, and death were calculated. A time-to-event analysis was performed for secondary intervention for any branch. Univariable and multivariable analyses were performed to identify related variables. Branch instability, a composite outcome of any branch event, was reported as a function of exponential decay to capture the loss of freedom from complications over time. RESULTS: Between the years 2001 and 2010, 650 patients underwent endovascular aortic repair with branched or fenestrated devices. Over 9 years of follow-up (mean [standard deviation], 3 [2.3] years), secondary procedures were performed for 0.6% of celiac, 4% of superior mesenteric artery (SMA), 6% of right renal artery, and 5% of left renal artery stents. Mean time to reintervention was 237 (354) days. The 30-day, 1-year, and 5-year freedom from branch intervention was 98% (95% confidence interval [CI], 96%-99%), 94% (95% CI, 92%-96%), and 84% (95% CI, 78%-90%), respectively. Death from branch stent complications occurred in three patients, two related to SMA thrombosis and one due to an unstented SMA scallop. Multivariable analysis revealed no factors as independent predictors of need for branch reintervention. CONCLUSIONS: Branches, after branched or fenestrated aortic repair, appear to be durable and are rarely the cause of patient death. The absence of long-term data on branch patency in open repair precludes comparison, yet the lower morbidity and mortality risk coupled with longer-term durability data will further alter the balance of repair options.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2013; · 3.52 Impact Factor
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ABSTRACT: We present the case of a patient diagnosed with hypermobile Ehlers-Danlos syndrome with aneurysms of the subclavian and vertebral arteries. Molecular testing demonstrated transforming growth factor-beta receptor type 2 mutation. She was not a candidate for an open repair; therefore, a hybrid approach involving right vertebral ligation and bypass from the right common carotid to the vertebral C1-2 interface, endovascular exclusion of the left vertebral artery, and stent grafting of the left subclavian/axillary artery was used. The left vertebral embolization proved ineffective, requiring a right-to-left vertebral catheterization with glue occlusion. Based on her proper molecular diagnosis, she underwent prophylactic root and ascending aortic repair.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2013; · 3.52 Impact Factor
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ABSTRACT: This study determined the effect of pulmonary disease on outcomes after endovascular abdominal (EVAR) and endovascular thoracoabdominal aortic aneurysm (eTAAA) repair.
A prospective study of high-risk patients undergoing EVAR and eTAAA repair between 1998 and 2009 was used to contrast clinical and endovascular outcomes between patients with (group 1) and without (group 2) chronic obstructive pulmonary disease (COPD). COPD patients were classified in accordance with the severity of their pulmonary disease using the Global Initiative for Chronic Obstructive Lung Disease criteria. Survival, morphologic changes, and complications were assessed using Cox models and life-table analyses. The cause and timing of deaths between the groups was compared.
Of 905 patients analyzed, 289 (32%) had COPD (group 1) and the remaining patients (group 2) did not have COPD. EVAR was performed in 334 patients (37%), and fenestrated or branched devices were used in the remaining 571 (63%). Group 1 patients were younger (73.5 ± 6.7 vs 75.6 ± 8.2 years), had a better glomerular filtration rate (67.8 ± 25.8 vs 61.0 ± 23.3 mL/min/1.73 m(2)), had higher hematocrits (41.6 ± 5.0 vs 40.5 ± 4.6), and had more extensive aneurysms. Mean follow-up was 39.5 ± 30.9 months. Early (3% vs 3%) and late (2% vs 1%) aneurysm-related deaths were similar between the two groups. Survival in group 1 depended on the severity of disease. Survival in patients with Global Initiative for Chronic Obstructive Lung Disease classification I and II was similar to group 2. Those with classifications III and IV demonstrated lower survival rates. Relevant pulmonary function test variables included a lower forced expiratory volume in 1 second and forced expiratory flow in the middle 50%, which were associated with decreased survival. Surrogate endovascular outcome analyses demonstrated that group 1 patients had fewer endoleaks (20% vs 25%; P = .05) and more rapid sac shrinkage rate (1.66 mm/y difference; P < .001).
The perioperative risk of death between COPD patients and non-COPD patients is eliminated when endovascular techniques are used. Long-term survival in COPD patients is most strongly related to the severity of their disease, and forced expiratory volume in 1 second and forced expiratory flow in the middle 50% are reasonable indicators of poor long-term outcomes. Morphologic changes after EVAR and eTAAA repair are more favorable in COPD patients, with a lower endoleak rate and faster sac shrinkage.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 10/2012; 56(4):911-919.e2. · 3.52 Impact Factor
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ABSTRACT: Accurate prediction of cardiac surgery-associated acute kidney injury (AKI) would improve clinical decision making and facilitate timely diagnosis and treatment. The aim of the study was to develop predictive models for cardiac surgery-associated AKI using presurgical and combined pre- and intrasurgical variables.
Prospective observational cohort.
25,898 patients who underwent cardiac surgery at Cleveland Clinic in 2000-2008.
Presurgical and combined pre- and intrasurgical variables were used to develop predictive models.
Dialysis therapy and a composite of doubling of serum creatinine level or dialysis therapy within 2 weeks (or discharge if sooner) after cardiac surgery.
Incidences of dialysis therapy and the composite of doubling of serum creatinine level or dialysis therapy were 1.7% and 4.3%, respectively. Kidney function parameters were strong independent predictors in all 4 models. Surgical complexity reflected by type and history of previous cardiac surgery were robust predictors in models based on presurgical variables. However, the inclusion of intrasurgical variables accounted for all explained variance by procedure-related information. Models predictive of dialysis therapy showed good calibration and superb discrimination; a combined (pre- and intrasurgical) model performed better than the presurgical model alone (C statistics, 0.910 and 0.875, respectively). Models predictive of the composite end point also had excellent discrimination with both presurgical and combined (pre- and intrasurgical) variables (C statistics, 0.797 and 0.825, respectively). However, the presurgical model predictive of the composite end point showed suboptimal calibration (P < 0.001).
External validation of these predictive models in other cohorts is required before wide-scale application.
We developed and internally validated 4 new models that accurately predict cardiac surgery-associated AKI. These models are based on readily available clinical information and can be used for patient counseling, clinical management, risk adjustment, and enrichment of clinical trials with high-risk participants.
American Journal of Kidney Diseases 12/2011; 59(3):382-9. · 5.43 Impact Factor
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ABSTRACT: Thoracoabdominal aortic aneurysms (TAAA) remain a challenging problem to manage. Operative care for patients afflicted with this devastating problem is associated with significant risks, including renal failure and paraplegia. Several techniques have been developed to help limit the risk for these complications, yet they still remain some of the greatest hurdles associated with these procedures. Endovascular technology is rapidly advancing and may provide an alternate approach to patients with TAAA. Endograft treatment of TAAA is possible with the use of fenestrated and/or branched aortic endografts. Although still early in its evolution, we are beginning to understand some of the risks and benefits of this approach to complex aortic disease. Fenestrated and branched aortic endografting may provide an option that has lower risk to patients. Spinal cord ischemia, however, still remains a critical problem in patients who require treatment of a significant portion of their aorta. In addition, renal failure is also still observed. The mechanisms leading to the development of these complications following endograft repair, however, may not be the same as observed with open TAAA repair. This review will highlight some of our current understandings of endovascular repair of thoracoabdominal aortic aneurysms.
Perspectives in Vascular Surgery 08/2011; 23(3):178-85.
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Journal of the American College of Surgeons 06/2011; 212(6):1094-6. · 4.55 Impact Factor
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ABSTRACT: Patients with chronic distal aortic dissection (CDAD) remain at high risk for late aorta-related events and reinterventions, and the ideal management strategy remains undefined. Open surgical procedures carry morbidity, but scant data for thoracic endovascular aortic repair (TEVAR) of CDAD exist. This study reports our intermediate-term results with TEVAR for complicated CDAD.
All cases of TEVAR for complicated (aortic growth, malperfusion, intractable pain) CDAD at our institution between 2000 and 2007 were retrospectively reviewed. Demographic information, indications for repair, complications, and aortic morphologic changes were collected from medical records and imaging studies. Aortic morphology (aneurysm size, false lumen thrombosis) was assessed at multiple levels with 3-dimensional image analysis techniques. Kaplan-Meier analysis was used to estimate survival, freedom from reintervention, and likelihood of false lumen thrombosis, with log-rank tests used to discriminate between Kaplan-Meier curves.
In total, 144 stent-grafts were implanted in 76 consecutive patients (49 male) with complicated CDAD. Early (<30 postoperative days) mortality was 5%. There was no paraplegia, and 1 patient died of stroke. At mean follow-up of 34 months, 12 patients had died (1 aorta-related death). Seventeen patients (22%) underwent 19 secondary aortic reinterventions, mainly for enlargement of the untreated aorta remote to stent-graft repair. Three secondary procedures treated retrograde proximal dissections. Estimated survivals were 86%, 82%, and 80% at 12, 24, and 36 months, respectively, and freedoms from both death and reintervention were 72%, 64%, and 59% at similar time points. Of 67 patients (88%) with complete imaging follow-up, TEVAR resulted in significantly decreased aortic diameter through the stent-grafted segment but not untreated segments. Complete thrombosis of the entire false lumen was uncommon in patients with extensive dissections (13% vs 78% P < .001).
Management of complicated CDAD remains challenging for clinicians. TEVAR is a reasonable treatment modality for dissections limited to the thoracic aorta and for prevention of focal aortic growth in extensive dissections. Late complications and the need for secondary interventions emphasize the complexity of this patient population and the need for long-term follow-up.
The Journal of thoracic and cardiovascular surgery 05/2011; 142(5):1074-83. · 3.41 Impact Factor
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ABSTRACT: A great deal of attention has been directed at the necessity and potential for deleterious outcomes as a result of radiation exposure during diagnostic evaluations and interventional procedures. We embarked on this study in an attempt to accurately determine the amount of radiation exposure given to patients undergoing complex endovascular aortic repair. These measured doses were then correlated with radiation dose estimates provided by the imaging equipment manufacturers that are typically used for documentation and analysis of radiation-induced risk.
Consecutive patients undergoing endovascular thoracoabdominal aneurysm (eTAAA) repair were prospectively studied with respect to radiation dose. Indirect parameters as cumulative air kerma (CAK), kerma area product (KAP), and fluoroscopy time (FT) were recorded concurrently with direct measurements of dose (peak skin dose [PSD]) and radiation exposure patterns using radiochromatic film placed in the back of the patient during the procedure. Simultaneously, operator exposure was determined using high-sensitivity electronic dosimeters. Correlation between the indirect and direct parameters was calculated. The observed radiation exposure pattern was reproduced in phantoms with over 200 dosimeters located in mock organs, and effective dose has been calculated in an in vitro study. Scatter plots were used to evaluate the relationship between continuous variables and Pearson coefficients.
eTAAA repair was performed in 54 patients over 5 months, of which 47 had the repair limited to the thoracoabdominal segment. Clinical follow-up was complete in 98% of the patients. No patients had evidence of radiation-induced skin injury. CAK exceeded 15 Gy in 3 patients (the Joint Commission on Accreditation of Healthcare Organizations [JCAHO] threshold for sentinel events); however, the direct measurements were well below 15 Gy in all patients. PSD was measured by quantifying the exposure of the radiochromatic film. PSD correlated weakly with FT but better with CAK and KAP (r = 0.55, 0.80, and 0.76, respectively). The following formula provides the best estimate of actual PSD = 0.677 + 0.257 CAK. The average effective dose was 119.68 mSv (for type II or III eTAAA) and 76.46 mSv (type IV eTAAA). The operator effective dose averaged 0.17 mSv/case and correlated best with the KAP (r = 0.82, P < .0001).
FT cannot be used to estimate PSD, and CAK and KAP represent poor surrogate markers for JCAHO-defined sentinel events. Even when directly measured PSDs were used, there was a poor correlation with clinical event (no skin injuries with an average PSD >2 Gy). The effective radiation dose of an eTAAA is equivalent to two preoperative computed tomography scans. The maximal operator exposure is 50 mSv/year, thus, a single operator could perform up to 294 eTAAA procedures annually before reaching the recommended maximum operator dose.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 02/2011; 53(4):885-894.e1; discussion 894. · 3.52 Impact Factor
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ABSTRACT: During the past several decades, the number of diagnostic tests and procedures that require the administration of radiation has increased dramatically. Understanding which factors affect radiation injury and how to mitigate these to protect patients has become critical for physicians to understand. Informed consent for these procedures has to include a discussion of the risks of radiation.
Factors that affect radiation injury, as well as ways to mitigate these, are discussed. Informed consent is also reviewed.
Technical factors of the radiation delivery and patient factors both influence the dose of radiation received. Minimizing exposure is critical, and close examination of the patient is warranted to diagnose radiation injury. True informed consent includes a frank discussion of the radiation risks as well as the benefits of the procedure.
Minimizing patient radiation exposure and accurately diagnosing radiation injury are key skills with which any physician ordering or performing tests or procedures requiring the use of radiation needs to be familiar. Informed consent includes a discussion of the risks as well as the benefits of the proposed radiation exposure.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2011; 53(1 Suppl):9S-14S. · 3.52 Impact Factor
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ABSTRACT: Endovascular repair of complex aortic aneurysms (CAAs) can be performed in high-risk individuals, yet is still associated with significant morbidity, including spinal cord ischemia, cardiac complications, and death. This analysis was undertaken to better define the cardiac risk for CAA.
A prospective database of patients undergoing thoracoabdominal or juxtarenal aortic aneurysm repair with branched and fenestrated endografts was used to retrospectively determine the number of cardiac events, defined as myocardial infarction (MI), atrial fibrillation (AF), and ventricular arrhythmia (VA), that occurred ≤ 30 days of surgery. Postoperative serial troponin measurements were performed in 266 patients. Any additional available cardiac information, including preoperative echocardiography, physiologic stress tests, and history of cardiac disease, was obtained from medical records. The efficacy of preoperative stress testing and the association of various echo parameters were evaluated in the context of cardiac outcomes using univariable and multivariable logistic regression models.
Between August 2001 and December 2007, 395 patients underwent endovascular repair of a thoracoabdominal or juxtarenal aortic aneurysm. The incidence of AF, VA, and 30-day cardiac-related death was 9%, 3%, and 2%, respectively. Overall 30-day mortality was 6%. Univariable analysis showed the presence of mitral annulus calcification was associated with MI (odds ratio [OR], 3.5; 95% confidence interval [CI], 0.9-13.8; P = .07). Left atrium cavity area, ejection fraction, left ventricle mass, and left ventricular mass index were univariably associated with the presence of VA. Multivariable analysis showed only the left atrium cavity area was independently associated with VA (OR, 1.2; 95% CI, 1.0-1.5; P = .07). Stress test was done in 179 patients. Negative stress test results occurred in 152 (85%), of whom 9 (6%) sustained an MI during the 30-day perioperative course. MI occurred in 2 of the 27 patients (7%) who had a positive stress test result.
Endovascular repair of CAA can be performed in high-risk individuals but is associated with significant cardiac risk. It remains difficult to risk stratify patients using preoperative stress testing. Echo evaluation may help to identify patients who may be more likely to develop ventricular arrhythmias in the postoperative period and thus warrant closer monitoring. Postoperative troponin monitoring of all patients undergoing repair of CAA is warranted given the overall risk of MI.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 01/2011; 53(1):21-27.e1-2. · 3.52 Impact Factor
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Tara M Mastracci
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ABSTRACT: The treatment of aortic aneurysm disease using endovascular stent grafts has evolved over the past 20 years. Extending this approach to aneurysms involving the visceral aorta has required development of fenestrated endografts. By creating branches to accommodate visceral vessels, the proximal landing zone can be chosen based on the adequacy of the aortic wall, rather than the constraints of visceral vessels. This allows for a more stable repair, and permits a minimally invasive approach in even very complex aneurysms. As the technology becomes more widespread, the use of these grafts has emerged from an experimental form to standard of care in some jurisdictions. Thus, many patients who might have previously been considered high risk for aneurysm repair are now candidates for surgery. This article outlines the basic concepts behind the development of fenestrated endografts, their current use, and the future of the technology.
Perspectives in Vascular Surgery 12/2010; 22(4):214-8.
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ABSTRACT: Do ß-blockers have an effect on the 30-day risk of major cardiovascular events in patients with or at risk of atherosclerotic disease undergoing noncardiac surgery?
Randomized controlled trial.
Multicentre trial in 190 hospitals in 23 countries.
In total, 8351 patients with or at risk of atherosclerotic disease undergoing noncardiac surgery.
Patients were randomly assigned by a computerized 24-hour phone service to receive extended-release metoprolol succinate 200 mg (n = 4174) or placebo (n = 4177). Treatment was started 2-4 hours before surgery and continued for 30 days.
Cardiovascular death, nonfatal myocardial infarction (MI) and nonfatal cardiac arrest.
Of those randomized, 8331 (99.8%) patients completed the 30-day follow-up. Fewer patients in the metoprolol group than in the placebo group had an MI (176 [4.2%] v. 239 [5.7%] patients; hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.60-0.089, p = 0.0017). However, there were more deaths in the metoprolol group than in the placebo group (129 [3.1%] v. 97 [2.3%] patients; HR 1.33, 95% CI 1.03-1.74, p = 0.0317). More patients in the metoprolol group than in the placebo group had a stroke (41 [1.0%] v. 19 [0.5%] patients; HR 2.17, 95% CI 1.26-3.74, p = 0.0053).
A perioperative ß-blocker regimen results in fewer MIs but is associated with an increased risk of stroke and perioperative death in patients with or at risk for atherosclerotic disease undergoing noncardiac surgery. Patients are unlikely to accept the risks associated with perioperative extended-release metoprolol use.
Canadian journal of surgery. Journal canadien de chirurgie 10/2010; 53(5):342-4. · 1.05 Impact Factor
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Journal of Endovascular Therapy 10/2010; 17(5):673-4; author reply 674-5. · 2.86 Impact Factor
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ABSTRACT: In contrast to endovascular repair (EVAR), the absence of rigorous imaging follow-up after open surgical repair (OSR) has rendered the perception that late failure (LF) is rare. Better understanding of associated factors with LF will help define OSR follow-up paradigms and perhaps alter initial repair strategy to facilitate treatment of LF. The aim of this study is to evaluate aspects of LF requiring intervention after OSR.
From 1998 to 2008, data were collected prospectively on 1097 patients who underwent an aortic endovascular repair. Patients undergoing intervention for LF contiguous with prior OSR were subjected to further analysis. The indication for reintervention was a maximal diameter >60 mm. Univariable and multivariable linear regression models were used to compare patients and disease variables (18 variables regarding age, comorbidities, family history, etiology, and extent) with time to LF.
LF of open surgical aneurysm repair was identified in 104 (9.5%) patients. Mean aneurysm diameter was 72 +/- 12 mm. Mean age at first repair and time between the two repairs were 61.4 +/- 10.0 and 10.8 +/- 6.0 years, respectively. When compared with the 993 other patients whose EVAR was their primary repair, LF patients were significantly younger at the time of their first repair (61.4 +/- 10.0 vs 74.1 +/- 9.6 years; P < .00001) and more frequently had a family history of aneurysms (20% vs 7%; P = .001). They were also more likely to have presented with dissection, renal insufficiency, and manifestations of atherosclerosis. On multivariable analysis, patients with an initial incomplete OSR (aneurysm located in another aortic segment but not treated at the time of the primary repair), more extensive aneurysms (those involving the descending thoracic or the thoracoabdominal aorta), and older patients experienced earlier LF (P < .00001, .002, and .001, respectively). Although we were incapable of determining the incidence of LF after OSR, 34% of patients presenting with LF were regional to our center.
Aneurysmal disease is an ongoing process potentially involving the entire aorta. Segments that appear normal prior to OSR of EVAR may be vulnerable to LF. We identified several groups of patients following OSR who mandate more aggressive follow-up given their propensity to present with LF. The threshold and strategies guiding reintervention in the setting of LF is dependent upon many factors relating to the structure and the morphology of the aorta and implanted graft, the type of anastomosis, and patient comorbidities. Therefore, surgeons should consider LF treatment options when planning an aneurysm repair in an effort to optimize any later interventions, and have specifically tailored follow-up paradigms.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 08/2010; 52(2):272-81. · 3.52 Impact Factor
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Tara M Mastracci
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ABSTRACT: OPINION STATEMENT: The use of endovascular modalities for the treatment of simple descending thoracic aneurysms has become standard of care. Expanding endovascular techniques for the treatment of thoracoabdominal aneurysms is now possible with the evolution of branched and fenestrated grafts.
Current Treatment Options in Cardiovascular Medicine 06/2010; 12(3):205-13.
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ABSTRACT: To determine the renal artery to aorta relationship in the setting of thoracoabdominal aortic aneurysm (TAAA) in order to help strategize preoperative stent-graft planning, device design, and deployment technicalities.
The preoperative computed tomography (CT) studies of 147 patients who underwent TAAA repair between 2005 and 2008 were retrospectively reviewed. The Crawford classification of the TAAA, the renal artery implantation angle (RAIA), and the maximal aortic diameter were determined using 3-dimensional imaging analysis (centerline of flow). RAIAs were determined to be positive or negative as a function of their relative position above or below the plane perpendicular to the centerline of flow at the level of the renal ostia. RAIAs and maximum aortic diameters were compared between types II/III TAAA (n = 72) and type IV TAAA (n = 75), stratified by side, and examined for correlation.
Maximal aortic diameter was not significantly different between the 2 groups: 67.5+/-13.4 mm for type II/III versus 65.3+/-12.5 mm for type IV (p = 0.3). There was no correlation between the maximal aortic diameter and the RAIAs. RAIAs in type II/III TAAAs were commonly orthogonal to the aortic centerline (mean -5.7 degrees +/-19.1 degrees on the right and -2.8 degrees +/-22.4 degrees on the left, respectively), while type IV TAAAs had downward pointing renal arteries (mean -24.1 degrees +/-18.4 degrees and -20.4 degrees +/-18.8 degrees for the right and left, respectively). There was a significant difference between the two groups regarding RAIAs on both sides (p<0.00001).
The primary location of longitudinal aortic growth will drive the RAIA in a cranial or caudal direction. When the disease process is largely located below the renal ostia, infrarenal aortic lengthening drives the renal ostia cranially, forcing the implantation angle of the renal ostia to be caudally directed. The opposite occurs in type II or III TAAAs, where the bulk of disease is above the renal arteries, driving the ostia down to create RAIAs that are nearly orthogonal to the centerline of flow. Utilization of this data could result in endovascular grafts designed with branches replacing fenestrations for renal artery perfusion.
Journal of Endovascular Therapy 06/2010; 17(3):380-7. · 2.86 Impact Factor
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ABSTRACT: Long-term survival benefit contrasted with rupture risk should determine which patients are suitable for abdominal aortic aneurysm (AAA) intervention. Our aim was to develop a model capable of predicting long-term survival based on preoperative characteristics.
A prospective cohort study using Cox regression modeling. We aimed to associate preoperative characteristics with long-term mortality, and create a predictive nomogram, which was then externally validated on an independent cohort (697 patients) who underwent endovascular abdominal aortic aneurysm (AAA) repair.
We pooled the results of 412 patients undergoing endovascular repair of infrarenal and juxtarenal aneurysm who were high risk (average Glasgow aneurysm scores of 72.8 [SD 10.4]). Despite anatomic differences, there were no statistically significant differences in perioperative or long-term outcomes between infrarenal and juxtarenal aneurysms (log rank test, P = .5). Data from this group (64% infrarenal aneurysms and 36% juxtarenal aneurysms) were randomly and evenly split into a model development and test group. Independent predictors of mortality included in the model are age, aneurysm diameter, history of peripheral artery disease, chronic obstructive pulmonary disease (COPD), or congestive heart failure, requirement for supplemental home oxygen, and use of salicylates. Internal validation reveals good calibration and discriminative ability (c-statistic 0.68 [95% confidence interval 0.65-0.71]). External validation confirms good calibration.
In the context of acceptable perioperative results, long-term mortality risk can be predicted in endovascular AAA repair and must be balanced against risk of rupture to determine which patients should be offered treatment.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 05/2010; 51(5):1088-1095.e1. · 3.52 Impact Factor
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Journal of the American College of Cardiology 02/2010; 55(6):607. · 14.16 Impact Factor
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ABSTRACT: The objective of this study is to assess the impact of surgery on quality of life (QOL) in patients who underwent thoracoabdominal aortic aneurysm (TAAA) repair.
This is a prospective single center cohort study using two quality of life questionnaires administered before surgery, at 6 months, and 1 year after surgery. The Illness Intrusiveness Rating Scale (IIRS) is a tool that on a 7-point Likert scale assesses the impact of disease on each of 13 domains of quality of life. The Karnofsky Activity Scale (KAS) uses a single rating to assess the impact on overall quality of life. At each visit, participants completed the IIRS and KAS. Healthy, nonaneurysmal individuals also completed the IIRS to form a control group.
From 1998 to 2006, 297 patients underwent thoracoabdominal aneurysm repair at a tertiary care hospital. Quality of life was measured on 80 patients in total. Preoperative data was available in 45 patients (7 completed the IIRS and 3 the KAS only, and 35 both); 6-month postoperative data in 25 (1 completed the KAS only, and 24 both); and 1-year data postoperative in 35 (4 completed the IIRS and 2 the KAS only, and 29 both). Internal consistency was established for IIRS (Cronbach's alpha 0.85) and KAS (0.81). The mean preoperative IIRS score was 32.10 (SD 17.91). After surgery, there was no change at the 6-month and 1-year postoperative intervals: at 6 months, the mean IIRS score was 33.17 (SD 17.66) and at 1 year the mean was 28.09 (SD 13.61). Total IIRS in nonaneurysmal controls was 13.5 (SD 0.7). The mean preoperative Karnofsky Activity Scale score was 80.0 (SD 15.07), which corresponds to an ability to perform normal activity with effort and some signs or symptoms of disease. After surgery, there was no change as patients reported a 6-month mean score of 79.60 (SD 21.89), and a 1-year postoperative mean score of 86.94 (SD 13.94).
Quality of life for patients undergoing TAAA repair who survive to attend follow-up in an ambulatory setting can be measured using reliable and valid instruments. Preoperatively, QOL is poor compared with healthy controls. After surgery, at 6- and 12-month follow-up, QOL seems to return to the preoperative levels. Further research is necessary to address responsiveness and sensitivity of QOL measuring tools.
Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 09/2009; 50(2):251-5. · 3.52 Impact Factor
